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nate's mas1 

e wrongs 

lan to stamp out 

sikg error prosecutions pages 5 and 22 


Your guide to sip supplements page 16 


How retirement changes will hit your 

Tell me Nathan, 

how does FOSTAIR 

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for use with 
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In between number-crunching and 
biscuit-dunking, FOSTAIR is there 
for his asthma. 

It delivers twice as much medication 
to the lungs as standard metered-dose 
inhalers. 12 

A third of the extra-fine particles 
reach the small airways, 1 enabling 
uniform treatment of inflammation 
and bronchoconstriction throughout 
the lung. 3 4 

So by helping patients get control 
of their asthma, 5 they can get on with 
the serious business of really living. 

t 1 1 _ 

Have your say on C+D's news. Email us at: 


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firstname. surname 

{those first 
fallings of the 
axe look set to 
turn into a full- 
blown massacre 
as more local 
services are lost 
or reduced 5 

"The first cut is the deepest," 
warbled Cat Stevens in the swinging 
sixties. If only his much-covered hit 
had been a prophecy for pharmacy 
services in this era of austerity. 

If only, after the coalition 
government unveiled its first, brutal 
budget, the rumblings we heard last 
month of minor ailments services 
being slashed were the end as well 
as the beginning of pharmacy's 
worst nightmare. 

Instead, those first fallings of the 
axe look set to turn into a full-blown 
massacre as, after last week's bad 
news about Surrey pharmacists' 
smoking cessation service, C+D 
reports the loss of or reduction in 
more local enhanced services (p4). 

The good news is that pharmacy 
services are proving their worth, as 
the story that southern pharmacies 
were last year responsible for a 
significant proportion of their 
PCTs' smoking cessation successes 
(p5) shows. 

These are the sorts of figures we 
should, as has often been pointed 
out on this very page and elsewhere, 
be gathering more of; if we wave 
such evidence of pharmacy services' 
value under PCTs' noses they'll 
have no choice but to keep running 
them, right? 

Er, wrong - if PSNC's Alastair 
Buxton is to be believed. His 
assessment that trusts are ignoring 
hard facts in favour of an instant fix 
on the bottom line (p4) calls to mind 
an image of PCT officers running 

around like headless chickens that 
might be amusing if pharmacists' 
livelihoods weren't at stake. 

It gets worse. Not only are PCTs 
discounting positive evidence in the 
rush to record a healthy balance 
sheet but one smoking cessation 
scheme has become the definition of 
"a victim of its own success", 
cancelled after it was so efficacious 
it "outstripped its budget" (p4). If 
that isn't a perverse system, I don't 
know what is. 

I don't doubt PCTs are under 
enormous pressure to cut costs, and 
that temptation to do so by any 
means is huge. But to avoid potential 
long-term damage - to the invaluable 
community pharmacy network and 
the wider health service as well as 
patient care - they really must take a 
step back and a deep breath, and 
look at the bigger picture. 

And if PCTs won't respond to the 
carrot, perhaps pharmacies will have 
to start using the stick. That's the 
approach taken by one LPC, which 
has highlighted the probable negative 
consequences of cutting its minor 
ailments scheme (p8). Crowded 
surgery waiting rooms and A&E 
departments full of victims of 
chesty coughs rather than car 
crashes - it's not pretty. But perhaps 
showing PCTs their worst-case 
scenarios is the only way to avoid 
pharmacists' own. 

Jennifer Richardson 
Features Editor 

4 More enhanced services axed 

5 Pharmacies help hit smoking goals 

6 Tutor avoids striking off over exam fixes 
8 NHS to foot bill from MAS cutbacks 

10 Society blasts CPhC over fee hike plan 

12 New name for Corlan pellets 

13 Letters 

14 Xrayser 

15 Nick Barber and letters 
24 Classified 

30 Postscript 


Update: adult oral sip supplements 

Your guide to ONS products 

Practical approach 

Pain around the eyes following a cold 

Ethical dilemma 

Can you take the easy route to MURs 7 

Health and wellbeing at work part 5 

How to avoid work-related injury and illness 

22 The C+D Senate 

Defending against dispensing errors 


How changes in retirement law will affect you 





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Press, Queens Road, Ashford TN24 8HH Registered at the Post Office as a Newspaper Volume 274 No 6759 



More enhanced services axed as 
PCT cutbacks spread to the north 

Stop smoking and minor ailment services suspended or scaled back in north west England 

Chris chapman pharmacy services as they see Pharmacy services in England - the highs and lows bottom line quick savings. We're 

seen to be a particularly soft target." 

Pharmacies in the north west have However, Tameside and Glossop 

seen services vanish or shrink, with PCT offered a ray of hope, vowing it Minor ailments service cut from 

two PCTs cutting minor ailments would try to save the service. / \ September 

(MAS) or smoking cessation services. Pharmacies had been so successful -r \ 'I East Lancashire 

Tameside and Glossop PCT has in helping quitters the service had 

cancelled its smoking cessation outstripped its budget, the PCT said. J y ~*s r ^~' Minor ailments service formulary 

service, and Blackburn with Darwen Mark Collins, PSNC north western / \ \ reduced and visit limited 

Teaching PCT will suspend its MAS regional representative, said the 

through pharmacies from future of services through \ { \ 

September. pharmacies in the region was "pretty \i as^-^^t Tameside and GloSSOp 

East Lancashire PCT has also much doom and gloom", 

reduced its minor ailments service, "The prospect of reduced income ^ ^\ /-^_^^ f Pharmacy smoking service 

with the formulary slashed and is really scary, and we've had to tell f \ "outstripped budget" 

patients allowed only a limited patients they can't use the service," 

number of visits before they must he said, 

use CP services. However, Mr Collins praised 

The cuts come just one week after pharmacist colleagues working in 

C+D revealed the loss of a stop- the PCT, despite the cuts, 

smoking scheme in Surrey. "Pharmacist advisers put a lot of 

Lloydspharmacy director Andy work in - but they're told by bean 

Murdock hit out at the cuts, warning counters services have got to go. 

that PCTs were "cutting off their They're devastated," he added. 

, , v /> \ \ * burreu 

noses to spite their faces" with a Easy Lancashire PCT said the cost ^~k_^J> \ 

narrow outlook. of its pharmacy MAS had exceeded / ? ( Pharmacy smoking cessation 

He said: "If we are going to have forecasts and had been scaled back / ~X A >s services scrapped in favour of 

greater efficiency in the NHS it because of financial pressures. /^"V S~^^ T telephone service 

would make sense to move Blackburn with Darwen Teaching \ T[ J 491 

treatment to the right place. In my PCT was contacted about its cuts, 

view pharmacy is the best place [for but had not responded as C+D went 

minor ailments). to press. 
"If you look at the cost of 

pharmacy, it is cheaper. If you're 

increasing access, and doing it 

cheaper... it's a false economy [for 

PCTs to cut services]." -r \ t*s*~^^\ ^ — ^^"^ 

Ian Short, secretary for Oldham, S 1 
Tameside and Glossop LPC, said the 
committee was considering whether 

to contest the loss of its the v 

cessation service in its area. Hampshire 

Pharmacy was a "soft target" that More than a third of patients who 

could ■ furthei cuts, he warned iBnHmHEiiHHH! stopped smoking in 2009 10 did Pharmacists helped 2,087 

He said: "I deal with four PCTs and so through pharmacies patients quit smoking in 2009-10 

all are aggressively reviewing 

PCT cuts beyond our control, warns PSNC 

Service cuts are beyond the control 
of national pharmacy bodies, with 
PCTs basing the decisions on cost 
not evidence, PSNC has warned. 

Speaking exclusively to C+D, 
PSNC head of NHS services Alastair 
Buxton warned the "hard and honest 
truth" was that there was "precious 
little" the committee could do 

to save services. "The best way 
forward in the medium to long term 
is to enhance the evidence base... 
but I don't think that's going to help 
as evidence isn't being used - it's 
what the PCT can afford to chop," 
he said. 

PSNC had appointed a new staff 
member to collate the evidence base 

for pharmacy services, pulling 
together small-scale studies to 
create a national picture, Mr 
Buxton added. 

English Pharmacy Board chair 
Lindsey Gilpin said the situation 
emphasised a "PCT postcode 
lottery", and that the RPSGB 
would lobby the Department of 

Health for support. She said: 
"We need to make it clear to the 
government the way isn't to 
abandon everything. This short- 
termism doesn't help. We need 
national guidance." 

The national pharmacy bodies 
would be working together to look 
for solutions, Ms Gilpin added. CC 

4Chemist+Dr ggist 28.08.10 

Video: C+D Senators on defending against dispensing errors 


Pharmacies defy cuts to 
hit stop smoking targets 

Hampshire and Dorset help thousands of patients to quit 

Chris Chapman 

chris.chapmart ( 

Pharmacies on the south coast are 
defying enhanced service cuts to see 
their stop smoking schemes thrive 

Pharmacists in Dorset were 
responsible for more than a third of 
the 2,328 patients who managed to 
give up smoking between April 2009 
and March 2010. 

Pharmacists in Hampshire were 
also celebrating success, having 
helped 2,087 of the 8,328 patients 
who quit in the county - 23 per cent 
over the PCT target. 

Nationally, more than 750,000 
people tried to give up smoking 
through the NHS in 2009-10, with 
almost 374,000 successful quitters 
at four weeks, the Department of 
Health said. 

The government was currently 
reviewing how to move forward with 

stop smoking services, said health 
secretary Andrew Lansley. He said: 
"Smoking is the biggest preventable 
cause of death in England. We are 
now reviewing how best to tackle 
this issue in the context of the new 
priority and focus on public health 
by the government." 

Last year around 81,400 deaths - 
18 per cent of deaths in adults aged 
35 and over - were estimated to be 
caused by smoking There were 
around 1.5 million hospital 
admissions with a primary diagnosis 
of a disease that can be caused by 
smoking in 2008-09. 

C+D fights for pharmacy on BBC Radio 

C+D clinical editor Chris Chapman 
appeared on BBC Radio Surrey's 
breakfast show last week to 
hammer home the importance of 
stop smoking services through 

Mr Chapman joined Surrey LPC 
secretary Martin Mandelbaum in 
warning patients would lose out 
due to the service withdrawal in 
the area. Mr Chapman said: "Still 

around one in five people in the 
country smoke... we really need to 
help these patients to give up as an 
NHS goal for public health." 

NHS Surrey told the BBC the 
pharmacy enhanced service was 
"not good value for money", and a 
phone support scheme had proven 
more cost effective and efficient. 

To listen to the interview, go to 

Senate urges rethink in errors fight 

Guidance produced on single 
dispensing errors by the Crown 
Prosecution Service (CPS) does not 
go far enough in protecting 
pharmacists, the C+D Senate has 

But rather than just pushing for a 
law change, which could be a 
lengthy process, the profession 
should focus on reducing errors and 
could lobby the attorney general, 
the Senators agreed 

Senator and lawyer David 
Reissner said although the CPS 
guidance was designed to make 
prosecutors think twice about 
bringing cases against pharmacists, 
all it had done was to restate the 
code for deciding whether to 

"But that code was in place at the 
time Elizabeth Lee was charged," he 
warned. "If prosecutors now were 
brought under pressure by families 
or by police there is no reason to 
suppose the situation would be 
particularly different." 

Pharmacists agreed they did not 
feel protected by the guidance and 
Mr Reissner continued: "I would 
make representations to the 
attorney general who is responsible 

Mark Koziol: CPS guidance gives defence teams "more to get their teeth around" 

for the CPS. I would say that this 
statement doesn't do the job and 
then say I wanted the CPS to say it 
wouldn't bring a prosecution 
without consulting the regulator." 

Senator Mark Koziol of the 
Pharmacists' Defence Association 
said the guidance did give defence 
teams "more to get their teeth 
around", but agreed prosecutions 
could still happen. 

The Senate also called for a 
culture shift to encourage error 
reporting and said pharmacists must 
make reducing errors a priority. 
Rowlands Pharmacy area manager 

and Senator Debby Crockford 
concluded: "If humans are involved 
there are always going to be errors 
and the only way to improve 
practice is to self-report those." 

The Senators discussed the 
Elizabeth Lee case after C+D readers 
unanimously voted for the topic 
to be on the agenda at the C+D 
Senate ZS 

The full verdict on 
dispensing errors 

More on the Senate page 22 

Tesco's super Price 

Adrian Price has joined Tesco as 
superintendent pharmacist. Mr 
Price, formerly Co-operative 
Pharmacy clinical commercial 
manager, replaces Penny Beck, 
who has taken early retirement. 

Boots service pilot 

A Boots pharmacy in the centre of 
Edinburgh has launched a range of 
walk-in services as part of a 
Scottish Government pilot. The 
multiple has teamed up with NHS 
Lothian to offer services ranging 
from nurse-led minor illness and 
injury treatment and sexual health 
advice to simple diagnostic 
healthcare checks and tests. 

AZ strikes: no impact 

Strikes at AstraZeneca's major UK 
manufacturing site will have 
"minimal" impact on medicines 
supply to pharmacies, the 
pharmaceutical giant has said 
This week union GMB announced 
three dates of strike action during 

Read more on the above stories at 

Non-emergency? Dial 111 

A new telephone number for non- 
emergencies has been launched in 
north east England. The 111 
service, which is being piloted in 
Durham and Darlington, offers 
medical advice and signposting to 
pharmacies. The service will be 
rolled out to Nottingham, Luton 
and Lincolnshire later this year. 

Dronedarone for AF 

Nice has recommended 
dronedarone as a second-line 
treatment for patients with AF not 
controlled by first-line therapy, 
who have additional cardiovascular 
risk factors. Last year a meta- 
analysis found the drug was less 
effective at preventing AF 
recurrence than amiodarone, but 
had fewer side effects. 

Migraine aura mortality 

Patients who suffer migraine with 
aura are at increased risk of all- 
cause mortality. Reporting in the 
BMJ, researchers from Iceland 
found patients with migraine 
without aura were not at 
increased risk. 




Video: Teva introduces its generic OTC range 

NCSO update 

The Department of Health and 
National Assembly for Wales have 
agreed to allow NCSO 
endorsements for the following 
items for August prescriptions: 
ofloxacin 400mg tablets. 

Lloydspharmacy pre-reg 

Lloydspharmacy has partnered 
with an NHS Foundation Trust 
to create a pre-reg programme 
that includes placements in 
community and hospital 
pharmacy. Under the scheme, 
two trainees will work for six 
months in each organisation. 

Colic medicines shunned 

Nearly two thirds of health 
professionals are very concerned 
about giving medicines to young 
babies to ease colic symptoms, 
according to research. More than 
half of the 253 respondents said 
that they would prefer to advise 
patients to switch feeding bottles 
instead, market research company 
Consumer Analysis said. 

Sex ed essential 

The Faculty of Sexual and 
Reproductive Health has called for 
sexual health services to become 
a public health priority. The 
comments came in response to 
Office of National Statistics data 
that showed a small rise in 
teenage pregnancies over the 
past quarter. 

Blood pressure test bid 

More than 1,400 pharmacies, 
supermarkets, shopping centres, 
workplaces and community 
venues will set up blood pressure 
stations as part of the Blood 
Pressure Association's Know Your 
Numbers Week. The event takes 
place from September 13 to 19 
and aims to tackle poor awareness 
of blood pressure among adults. 

Tutor avoids striking off 
over exam fixing incident 

De Montfort academic 'put under pressure' to inflate students' marks 

Max Gosney 

A pharmacy tutor who fixed exam 
papers to ensure students passed 
can carry on practising as a 
pharmacist, the RPSCB disciplinary 
committee has ruled. 

Janet Eden, a former tutor at De 
Montfort University, received a 
warning as the panel acknowledged 
the "exceptional" nature of her case. 

In May 2007, Mrs Eden doctored 
the papers of seven students taking 
a microbiology and biotechnology 
exam to help them hit pass marks. 

The incident followed pressure 
and hostility from colleagues, the 
disciplinary meeting heard. 

Mrs Eden, of Leicester, had 
previously denounced a move by De 
Montfort University in 2004 to 
boost students' marks to increase 
pass rates. 

Mrs Eden had told colleagues they 
"had all gone mad" to consider 
inflating marks, according to a 
statement by Joan Taylor, professor 
of pharmaceutics at De Montfort. 

Mrs Eden was "publically 
humiliated in the most grotesque 
way" in the meeting and began to 
"crumble over the next two years", 
according to Professor Taylor. 

Three years later, Mrs Eden said 
she had been told by a colleague of 
his "disappointment in my marks" 
on seven borderline papers. These 
were "considerably lower" than 
those of two other academics, Mrs 
Eden said she was told. 

"I distinctly remember returning 
to my desk after the meeting with 
the thoughts in my head that... if he 
wanted the marks altered, he will 
get them altered," Mrs Eden told the 

Mrs Eden had made a full 

confession at the earliest possible 
moment, the committee 

The panel also recognised the 
incident was a single blemish in a 
35-year career. 

Panel chairman Patrick Milmo QC 
said: "We think there has been full 
insight into the enormity and 
seriousness of what she did." 

The panel stressed conduct 
involving dishonesty should be 
regarded as the highest level of 
misconduct and usually attracted a 
striking off or suspension. 

But, Mr Milmo concluded: "We 
are convinced there is no prospect 
at all of repetition as she has no 
intention of returning to the 
academic world and in our view 
there is no realistic prospect of 
any dishonest or similar conduct 
being committed by her as a 
locum pharmacist." 

GP systems firm buys Rx Systems 

Pharmacy software and services 
company Rx Systems has been 
bought by EMIS, the UK's largest CP 
systems firm, in a £10 million deal. 

The acquisition gave the potential 
for greater integration between 
pharmacy and GP IT systems, EMIS 
told C+D. 

A spokesperson for the company 
said: "It is too early to say in detail 
how we will develop the integration 
between the EMIS GP systems and 
the ProScript system. 

"However, there is clearly 
potential to enhance the message 
flows between the patient, GP 
and pharmacist - including EPS 
message flows - and this is 
something we will be actively 
investigating in the coming months." 

The company added that it could 

Rx Systems currently has a 20 
per cent share of the community 
pharmacy market, with 2,500 
community pharmacies using the 
company's ProScript dispensary 
management system. 

Further growth could be achieved 
following the acquisition, according 
to EMIS. 

The acquisition is also important 
for the provision of 'joined-up' 
healthcare for NHS patients, the 
company said. HF 

The deal could see more integration 
between pharmacy and CP IT systems 

anticipate future integration of EMIS 
and Rx Systems technologies that 
could enable further streamlining of 
electronic prescription services. 

Pharmaceutical M1M Your GPhC information pack 
Council I ffll will arrive by post soon 

Cegedim Rx gets EPS2 
approval from 
Department of Health 

See page 10 

6 Chemist-Drueeisi 28.08.10 

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NHS to foot the bill 
from MAS cutbacks 

Patients would swamp costly GP and A&E services, LPC survey finds 

A national minor ailment scheme could save the NHS more than £2 billion a year 

Chris Chapman 

Eight out of 10 patients accessing 
minor ailment services (MAS) would 
go to a CP rather than pay for their 
medicine if the service was cut, a 
survey has found. 

The week-long survey by East 
Lancashire LPC saw 36 pharmacies 
ask minor ailment patients where 
they would go if the pharmacy did 
not offer the MAS scheme. 

Of the 376 patients asked, 312 (83 
per cent) said they would access 
their GP rather than a pharmacy. 
Only 23 per cent of those asked said 
they would buy a product, with 25 
(7 per cent) saying they would have 
gone to A&E instead. 

One respondent said they would 
go to A&E for their chesty cough 
because they could never get an 
appointment with their CP. 

According to the Self Care 
Campaign, which aims to reduce GP 

The latest statistics on sexually 
transmitted infections in the UK 
are just stunning. There is simply 
no other word for it. And it's a 
problem that means pharmacists 
have their work cut out. 

According to data from the 
Health Protection Agency released 
this week, there were 482,696 
diagnoses of an STI in the UK in 
2009 - up 12,000 on 2008. Two 
thirds of diagnoses in women were 
in those under 25; for men, just 
over half. The peak age for an STI in 

consultations for minor ailments, a 
visit to a GP costs the NHS £32, a 
visit to A&E £111 and self-care up 
to £3.50. 

According to these figure, the 
36 pharmacies saved the NHS 
£12,169.25 during the study period - 
around £17,650 per pharmacy every 
year, or more than £2 billion per year 

the UK is now between 19 and 20 for 
men, and 20 to 23 for women. 

In terms of geography, STI 
hotspots include London, Brighton 
and Hove, Nottingham, Manchester 
and Southampton. Men who have 
sex with men remain an at-risk 
population, with high rates of STIs 
reported in this group. 

To my mind, one of the most 
worrying statistics is the reinfection 
rate. One in 10 under 24-year-olds 
diagnosed with an STI will become 
reinfected within a year. This figure 
serves to emphasise not only how 
important chlamydia screening is as 
an enhanced service, but how 
important it is to get the safe sex 
message to young people. Tips are 
available at www.chemistand 

Another ominous statistic caught 
my eye. Rates of gonorrhoea in the 
UK increased by 6 per cent compared 
with 2008, up to 17,385 cases. 
Worse, resistance to cefixime, the 
first-line treatment, has increased 

if the scheme were adopted 
nationally. The findings come as 
PCTs across England cutback on 
pharmacy MAS (C+D July 24/31, p5). 

Dr Paul Stillman, a Sussex GP and 
member of the Self Care campaign, 
said the results showed pharmacists 
could help treat patients and keep 
NHS costs down. 

from one in 1,000 cases to more 
than one in 10 in just four years. 

Bacterial resistance is an 
unfortunate reality for all 
conditions requiring antibiotics. 
But unlike the war against the 
likes of staph and strep, the 
transmission of gonorrhoea is 
easily preventable. The statistics 
show the vital importance of safe 
sex education, especially in young 
people and men who have sex 
with men. We need to make sexual 
health a public priority now - 
otherwise we may find ourselves 
facing an epidemic without the 
arsenal of drugs we need. 

To discuss this subject in 
private with your pharmacy 
colleagues, join the debate in 
C+D's Linkedin group at - search for 
Chemist and Druggist. 

Chat with Chris on Twitter: 

Abbreviated Prescribing Information for Dovobef* 
50 microgram/g + 0.5 mg/g Ointment 

Indications: Treatment of stable plaque 
psoriasis vulgaris amenable to topical 
therapy. Active ingredients: 50 pg/g calcipotriol 
(as hydrate) and 500 pg/g betamethasone 
(as dipropionate). Dosage and Administration: 
Apply once daily. Recommended treatment period 
is 4 weeks. After this period repeated treatment can 
be initiated under medical supervision. Maximum 
dose should not exceed 15g/day and lOOg/week. 
Treated area should not be more than 30% of body 
surface. Not recommended for use in people under 
18 years. Contra-indications: Hypersensitivity to 
any constituents. Patients with known calcium 
metabolism disorders. Viral skin lesions, fungal oi 
bacterial skin infections, parasitic infections, skin 
manifestations in relation to tuberculosis or syphilis, 
rosacea, perioral deimatitis, acne vulgar is, atrophic 
skin, striae atrophicae, fragility of skin veins, 
ichthyosis, acne rosacea, ulcers, wounds, perianal 
and genital pruritus. Guttate, erythrodermic, 
exfoliative or pustular psoriasis. Severe renai 
insufficiency or severe hepatic disorders. 
Precautions and Warnings: Avoid inadvertent 
transfer to scalp, face, mouth and eyes. Wash hands 
after applying. Avoid concurrenttreatment with other 
steroids. Adrenocortical suppression oi impact on 
the metabolic control of diabetes mellitus may occur. 
Avoid application on large areas of damaged skin, 
under occlusive dressings or on mucous membranes 
or skin folds. Skin of the face or genitals should be 
treated with weaker corticosteroids. There may be 
a risk of generalised pustular psoriasis. With long- 
term use there is an increased risk of undesirable 
local and systemic corticosteroid effects in which 
case treatment should be discontinued. There may 
be a risk of rebound when discontinuing treatment. 
No experience of use on scalp. No experience ol 
concurrent use with other antipsoriatic products or 
with phototherapy. Physicians are recommended to 
advise patients to limit or avoid excessive exposure 
to natural or artificial sunlight. Use with UV radiation 
only if the physician and patient consider that the 
potential benefits outweigh the potential risks. Use 
in Pregnancy and Lactation: Only use in pregnancy 
when potential benefit justifies potential risks. 
Caution when prescribed for women who breast 
feed. Instruct patient not to use on breast when 
breast-feeding. Side Effects: Pruritus, rash, burning 
sensation of skin. Additional undesirable effects 
observed for calcipotriol and betamethasone: 
Calcipotriol: application site reactions, skin 
irritation, burning and stinging sensation, dry skin, 
erythema, dermatitis, eczema, psoriasisaggravated, 
photosensitivity and hypersensitivity reactions 
including very rare cases of angioedema and facial 
oedema. Hypercalcaemia or hypercalciuria may 
appear very rarely. Betamethasone: local reactions, 
especially during prolonged application including 
skin atrophy, telangiectasia, striae, folliculitis, 
hypeitrichosis. perioral dermatitis, allergic contact 
dermatitis, depigmentation, increase of intra- 
ocular pressure, cataract, colloid milia, generalised 
pustular psoriasis, infections. Systemic effects occur 
more frequently when applied under occlusion, on 
skin folds, to large areas and long term treatment. 
Legal Category: POM Product Licence Number and 
Holder: 05293/0003. LEO Pharmaceutical Products, 
Ballerup, Denmark. Basic NHS Price: £32.99/60g, 
£61.27/120g. Last revised: March 2010. 

Adverse events should be reported. Reporting 
forms and information can be found at Adverse events should 
also be reported to Drug Safety at 
LEO Pharma by calling 01844 347333. 

Further information can be found in the 
Summary of Product Characteristics or from: LEO 
Pharma, Longwick Road, Princes Risborough, 
Buckinghamshire, HP27 9RR. 

® Registered Trademark 




1. Kaufmann R ef al Dermatology 2002; 205: 

2. Data on file. LEO Market Research Survey 
conducted with 483 patients and 500 
Healthcare Professionals, December 2009- 

3. Zaghloul SS and Goodfield MID Arch Dermatol 
2004; 140: 408-414. 

4. Kragballe K ef a/ Br I Dermatol 2006; 154: 

5. British Association of Dermatologists 
& Primary Care Dermatology Society. 
Recommendations for the initial management 
of psoriasis, lanuary 2010. Available at www. (last accessed 15 July 2010) 

6. Data on file (Psoriasis and Me) 
LEO Pharma 2010. 

Date of preparation: July 2010 1008/10763 

Clinical debate C+D's Chris Chapman looks at the evidence behind the headlines 

We can't afford wait in STI war 


Treatment advice for pharmacists 

Peel it. Treat it. Cawtroiit? 

Now is the time when patients may feel 
more self-aware about their psoriasis, as 
clothing switches to summer fashions. 

Consequently, more people may 
be seeking advice from healthcare 
professionals about how best to treat 
their condition. 


49% of patients with psoriasis do not fully comply with their 
treatment 2 , so it's important to recommend a therapy that 
patients can believe in when they feel their condition flare up. 


Once daily DOVOBET 51 has been shown to deliver fast and 
effective psoriasis therapy. 1 In fact, DOVOBET ,?1 is more 
effective than either a steroid alone 1 or calcipotriol alone", 
helping to build confidence, encourage patient compliance 
and ultimately promote treatment success. 3 

DOVOBET"" is well tolerated"and under medical supervision 
can be used for treatment beyond 4 weeks as required. 


Before treatment* 

After 6 days treatment 
with DOVOBET®* 

B.A.D guidelines encourage a greater patient involvement 
with their treatment plan. 5 Doctors are therefore advised to 
review their new patients after 4 weeks to assess progress 
and ensure that patients correctly understand how and when 
to use their treatment. 

Date of preparation: July 2010 1008/10763 

Prescribing information can be found on the adjacent page. 

To help with this process, LEO has produced a patient 
information pad that GPs and pharmacists can use when a 
patient has been prescribed 
DOVOBET" ointment. 


It has been shown that when used V { and 2 nd line, DOVOBET" 
can also help reduce the need for secondary intervention 
(referrals, phototherapy, systemic therapies and biologies), 
with potential savings of more than £55,000 for an average 
general practice over 2 years.** 6 

With recommended use of emollients in-between 
flare-ups, good advice and effective treatment can help 
control psoriasis in the community. 




betamethasone dipropionate 


Fast and effective psoriasis therapy 1 



120 g 

t In combination base. *Clinical photographs courtesy of Dr Rigopoulos. 
These pictures are illustrative of the effect achievable with DOVOBET . "Analysis 
based on a practice of 10,000 patients over 2 years, assuming 119 patients are treated. 
Savings based on difference in cost of treatment pathway vs calcipotriol bd 1st line and 
calcipotriol plus steioid 2nd line. 


The trials of buying a pharmacy - read Ravi's biog 


Should non- 
pharmacists be able 
to join the PLB? 

"Yes they 
should be 
to join as 
we are 
trying to 
as much 

integration as possible, and having 
technicians registered with the PLB 
would serve us well." 
Stephen Foster, Pierremont 
Pharmacy, Broadstairs, Kent 

"Yes and 
no. I think 
yes because 
it is good to 
get an 

outside of pharmacy, and no 
because people who are not 
pharmacists don't really understand 
how pharmacy works." 
Elaine Tang, Co-operative 
Pharmacy, Hyde, Cheshire 

Web verdict 

Yes 19% 

No 81% 

Armchair view: Pharmacists are not 
keen to share the professional 
leadership body, according to C+D's 
survey. More than four out of five 
respondents reported they did not 
think non-pharmacists should be 
able to join the body. 
Next week's question: 
Has your PCT cut any enhanced 
services in the past month? Vote at 

G PhC fails to justify fee 
rise plans, says RPSGB 

We don't want war, but increases must be challenged says Society 

Max Cosney 

The RPSGB has blasted the CPhC for 
hiking up fees without proper 

Costs were "contradictory" and 
"hard to justify", the RPSGB national 
boards said in response to proposed 
fees for the new regulator. 

The GPhC was also accused of 
breaking a promise on keeping 
retention fees down. The Society 
stressed the criticism was intended 
as a "robust challenge" on behalf of 
pharmacists and not an act of war. 

Graham Phillips, member of the 
English Board, told C+D: "The GPhC 
is asking for money on top of more 
money. But there is a complete lack 
of information explaining why." 

He added: "The GPhC has 
presented itself as an open and 
transparent regulator; it needs to 
demonstrate that from the start." 

Instead, rises had been made 
against an "assumed" increase in 
regulatory costs, the RPSGB said. 

Mr Phillips said the GPhC's 
proposed £262 retention fee was a 
key concern. The sector was 
promised in 2008 that combined 
fees for the new regulator and 

The RPSGB is accusing the GPhC of breaking a promise to keep retention fees down 

professional leadership body (PLB) 
would not exceed £395. The GPhC's 
proposed levy means the combined 
fees break the cap by £59. 

Mr Phillips acknowledged the 
promise on fees was first made by 
former RPSGB chief executive 
Jeremy Holmes. But he stressed the 
government had committed to the 
set up of a PLB and should provide 
full financial support. 

A proposed rise in attendance fees 
for GPhC activities and committees 
also drew fire from the Society. This 
signalled a 27 per cent hike against 
current RPSGB levies, it said. 

The comments came as part of 
the RPSGB boards' response to a 
GPhC consultation on fees that 
closed last week. 

The GPhC declined to respond to 
the criticism. GPhC chief Duncan 
Rudkin has previously stressed the 
regulator cross-checked against 
RPSGB fees to inform its proposals. 

Has the GPhC set fees 
too high? 

EPS rollout boosted with Cegedim Rx approval 

Cegedim Rx has completed the 
approval process for release 2 of the 
electronic prescription service (EPS) 
with its Pharmacy Manager system. 

The supplier has successfully 
completed the initial implementation 
phase and been given approval to 
start rolling out the system more 
widely. Initially it can install the 
system in up to 200 pharmacies. 

The Department of Health (DH) 
announced Cegedim Rx had passed 
the standard assurance process for 
introducing the system into a 

limited number of pharmacies 
across England. 

A DH spokesperson said this 
would ensure safe and steady 
progress was made and that 
Cegedim Rx had the capacity to 
successfully deliver, while increasing 
patient safety and efficiency, the 
spokesperson added. 

Cegedim Rx managing director 
Simon Driver said: "It's good to see 
significant progress with EPS as 
release 2 has the potential to deliver 
significant administrative and 

clinical benefits. Cegedim Rx will 
work closely with NHS Connecting 
for Health to identify the milestones 
and logistics of the next stage of the 
limited deployment." 

Other systems currently expected 
to be given rollout approval in 2010 
include ProScript Link and ProScript. 

Nexphase and Positive Solutions' 
Analyst PMR/lntegrated PMR and 
EPOS 1.11 are also predicted to 
begin and complete initial 
implementation in the last three 
months of the year. ZS 

Sue Sharpe: What next for the pharmacy contract? 

C+D Keynote Conference at the Pharmacy Show 

October 10-11 The NEC Birmingham 
Register for your free ticket at 

10 Chemist Druggist 28.08.10 

60mg & 120mg Capsules 

Auden Mckenzie Launches 

Audmonal™ 60mg Capsules & Audmonal Forte™ 120mg Capsules 

Now available from all major wholesalers 

Audmonal™ 60mg Capsules 
PIP Code: 355-3112 

EAN Code: 5060032242576 
AAH Code: ALV0009Y 
Phoenix Code: 8897191 
Alliance Code: 8101099 

Audmonal™ Forte 120mg Capsules 

PIP Code: 
EAN Code: 
AAH Code: 
Phoenix Code: 
Alliance Code: 






v »rine Citrate 

? 0m 8 Capsules 

100 Capsules 

T °"»"<rve «,..,, 

•Wtabta how.' 

•vmploni. ot 

For further information contact Auden Mckenzie (Pharma Division) Ltd , 

Mckenzie House, Bury Street, Ruislip, Middlesex, HA4 7TL, UK. 

Telephone: 01895 627 420, Fax: 01895 631 777, E-mail: 


Presentation: Audmonal 60mg Capsules and Audmonal Forte ,M 120mg Capsules Indication' Adiuncl in gastro-inlestinal disorders characterised by smooth muscle spasm, such as 
irritable bowel syndrome, painful diverticular disease ot the colon and primary dysmenorrhea Dosage and Administration Adults and Children over 12 years, 60-120mg 1-3 limes 
daily Contraindications Paralytic ileus Undosirnble effects: Nausea, headache, dizziness, pruritus, rash, hepatitis also reported Legal Cntoqory: P PL: 17507/ 0148/ 0149 
MA Holder: Auden Mckenzie (Pharma Division) Ltd, Telephone. 01695 627 420 All information correct at dale ot publication August 2010 Ret: NPD-LNCH08-10/AUD60-120 


Auden Mckenzie 

(Pharma Division) Ltd. 

Dexamfetamine Sulphate 
5mg Tablets 

As of 31st August 2010 

will be DISCONTINUED and replaced by 
Dexamfetamine Sulphate 5mg Tablets 

Available from all major Wholesalers from 1st September 2010 

Dexamfetamine Sulphate 5mg Tablets (x28) 

For further information contact: Auden Mckenzie (Pharma Division) Ltd.. 

Mckenzie House, Bury Street, Ruislip, Middlesex, HA4 7TL, UK 

Telephone: 01895 627 420. Fax: 01895 631 777, E-mail: 


Dexamfetamine Sulphate 
5mg Tablets 


Auden Mckeru,c 

28 tablets 

Narcolepsy. I0mg daily in divided doses. 
Cardiovascular disease including. 


Dexamletamme Sulphate 5mg Tablets Indication: Narcolepsy, Refractory ADHD (under specialist supervision) 
max ot 60mg daily Refractory ADHD, Adults 5mg twice daily, max ot 60mg daily. Child 6-18 years. 5-10mg daily, max 1mg/kg (up to 20mg) daily 
structural cardiac abnormalities, advanced arteriosclerosis, hyperexcitability, hyperthyroidism, history ot drugs or alcohol abuse. 
Special warnings and precautions: Caution required in patients with: anorexia, hypertension, psychosis or bipolar disorder, tics and Touretle syndrome, monitor growth in children, angle-closure 
glaucoma, avoid abrupt withdrawal, acute porphyria Undesirable effects: Insomnia, irritability, contusion, dependence and tolerance, gastro-mtestmal symptoms, tachycardia, myocardial infarction 
hypertension, visual disturbances, cardiomyopathy Contains Lactose and Sucrose. 


Auden Mckenzie (Pharma Division) Lid Telephone. 01895 627 420 All information correct at date ol publication August 201 


Auden Mckenzie 

(Pharma Division) Ltd. 


CE for counter staff - satisfy your PCT audit with Counterpart + 

New name for 
Corlan pellets 

Auden Mckenzie is renaming Corlan 
pellets, as Hydrocortisone 2.5mg 
Muco-Adhesive Buccal Tablets, from 

Hydrocortisone 2.5mg Muco- 
Adhesive Buccal Tablets are 
indicated for the treatment of 
mouth ulcers and work by reducing 
swelling and inflammation in the 
mouth, according to the company. 

The product is available from AAH 
Pharmaceuticals, Alliance 
Healthcare, Phoenix and Sigma 


2-5mg Muco-Adhesive 
Buccal Tablets 

JO ab'ets 

Price: £3.79/20 

Pip code: 115-6652 

Auden Mckenzie (Pharma Division) 

Tel: 01895 627420 

Dos and don'ts for headlice 

Nurse and headlice expert Christine Brown offered some dos and 
don't s for headlice, at the launch of Hedrin Once last week 

Do make sure parents use the 
treatment correctly. Hedrin Once 
needs to be used once but some 
treatments need to be used twice, 
with each application a week apart. 

Don't provide headlice treatment 
unless you are sure there are lice 
present. Ask customers to bring in 
a louse stuck to a piece of sticky tape. 

Do suggest parents check their 
children's hair once a week, and 
again two to three days after 
treatment if they require it. 

Don't support the use of electronic 
combs, or 'alternative' treatments 
that have not been shown to be 

D o nominate a member of staff to 
provide up-to-date information to 
customers about headlice. 

Don't encourage repeat use of 
treatment unless you are certain 
reinfection has occurred. 

Do suggest the whole family gets 
checked if headlice are found. 

Woundcare gel spray now 
available from Niche Generics 

Niche Generics has announced the 
launch of Flamizol Hydrocolloid 
gel spray. 

Flamozil is a paraben-free 
hydrocolloid gel that uses silver 
citrate as a preservative, says the 
company. The product is indicated 
for the care of local, dry or moist 
wounds and indirectly promotes 

wound healing by regulating the 
microenvironment of the wound, 
Niche Generics adds. 

Prices and pip codes: See C+D 
Monthly Price List or 
Niche Generics 
Tel: 01462 633800 

Superdrug launches Virtual 
mirrors' for cosmetics clients 

Superdrug is trialling 'virtual mirrors' 
that help customers choose 
cosmetics, in two stores. 

The mirrors allow customers to 
take photographs of themselves and 
use the touch screen to 'apply' 
cosmetics and experiment with 
different colours and strength of 
shades, free of charge. 

After taking a photograph using 
the inbuilt camera, customers can 
pick up a product from the stand in 

which the unit is contained (GOSH 
or Rimmel), scan the product and 
then the computer will 'apply' the 
product to the image. 

Customers can then email the 
images to their personal account, 
Facebook or Twitter pages, which 
will give them a record of the 
products they selected. 

The units are installed in 
Superdrug stores in Westfield, 
London and Meadowhall, Sheffield. 

Hedrin: G MTV, five, Sat 
Magicool: GMTV, five, Sat 
Magicool Plus: GMTV, five, Sat 
Panadol: All areas 
Savlon: All areas 

PharmaSite for next week: Pond's Cold Cream 
Cold Cream - in-store, Propain - dispensary 

windows, Pond's 

A-Anglia, B-Border, C-Central, C4-Channel 4, five-Channel 5, CAR-Carlton, 
CTV-Channel Islands, G-Granada, GMTV-Breakfast Television, GTV-Grampian, 
HTV- Wales & West, LWT-London Weekend, M-Meridian, Sat-Satellite, STV- 
Scotland (central), TT-Tyne Tees, U-Ulster, W-Westcountry, Y- Yorkshire 

How to moke the most of the 

CPD £25 million headlice market 



• New Pantoloc Control* 
(pantoprazole) for the short-term 
treatment of reflux symptoms (e.g. 
heartburn, acid regurgitation) in 
adults, for up to 28 days 

• Just one tablet a day provides up to 
24-hour day and night relief from 
reflux symptoms 

Relieves Heartburn 

{ Pantoloc 






Essential Information 

Pantoloc Control" 20mg gastroresistant tablets containing 20mg pantoprazole per tablet. For the short-term treatmenl of reflux symptoms (e.g. heartburn, acid 
regurgitation) in adults, for up to 28 days Legal Category: P. Further information is available from Novartis Consumer Health, Wimblehurst Road, Horsham, RH12 5AB, UK. 

12 Chemist +Druggis1 28.08.10 

Memoirs of a crime- 
fighting pharmacist 

Reading C+D's expose of the crime 
wave against London pharmacies 
(C+D, Aug 14, p6) reminded me of 
my own brush with the criminal 

When I was a young, fit, 23-year- 
old pharmacist, I literally took my 
life in my hands to manage probably 
the most dangerous pharmacy in 
London at that time. The previous 
manager was severely injured and 
needed stitches after attempting to 
apprehend thieves. 

I was an assistant junior instructor 
and former junior county and 
southern area judo champion at the 
time. One morning a guy came in 
with a forged private prescription I 
asked him to leave, at which point 
he swung a big right cross. I grabbed 
his fist, held him in a standard judo 
ground hold, applying an arm lock 
and stranglehold simultaneously. 

The old ladies in the pharmacy 
gave me a standing ovation. I later 
got a call from the surgery saying 
that the violent patient had returned 
and managed to assault one of 

On another occasion, I had to 
eject a violent customer who 
threatened to burn down the 
pharmacy. Normally guys who 
threaten don't act. Well, that rule 
definitely went out of the window: 
two weeks later I got a call from my 
boss saying that the pharmacy was 
on fire and it's all my fault! 

Another memorable moment 
involved a 6ft 2in burly biker. He 
presented a forged prescription and, 
to my dispenser's amazement, I 
invited the biker into the back room. 
I told him to take a seat before 
saying: "By the way you are nicked! 
I must warn you I am a judo expert, 
but if you don't give me any trouble 
you won't get hurt." 

The biker could not believe my 
audacity and actually sat down and 
made no attempt to escape. 

I phoned the local police station, 
who were open-mouthed in 
amazement. Within five minutes, 
two squad cars turned up with six 
excited young police officers. They 
were running around the pharmacy 
asking where he was. 

At that point he was just making 
his getaway. So I approached him 
from the rear, and grabbed him in a 
sumo grip around the waist. He 
couldn't move and the police 
handcuffed him. The next afternoon 
I was guest of honour for lunch at 
the local police station; I also got a 
commendation for bravery. 

I knew I was taking unnecessary 
risks and at that point was married 
with a child on the way. I knew it 
was time to move on. 

My career in community 
pharmacy only lasted for six years 
in the end. I nearly gave my last boss 
a heart attack. He used to say: 
"Gary, if you wanted to be a cop 
why didn't you?" He wasn't happy 
but I managed to squeeze in six 
citizens' arrests, mostly for forged 
prescriptions; we even had a stake- 
out in the pharmacy 

Would I do it all again? Yes, if I 
could sort out my back injury and 
lose 30lb. But, seriously, do not try 
this at home, folks. However, I do 
have some top crime fighting tips: 

• If you are working in a dangerous 
area, make sure there is a security 
barrier between you and the public 

• Get a security guard if you can 
afford one 

• Make sure you get regular high 
profile visits from local police 

• Make sure you have a panic 
button to the local police station 

• If confronted by a criminal then 
stay calm and stick together 

• Never open or close the pharmacy 
on your own - this is when you are 
most vulnerable. 

Gary Lewis, managing director, 
A1 Pharmaceuticals 

Contains Crotamiton 

Eurax has been available 
worldwide for over 60 years 
and is the medicines cabinet 
essential to relieve itchy or 
irritated skin. 
Itching can be caused by 
physical irritation or by chemical 
changes in the skin due to 
allergy, disease, inflammation or a reaction to irritant 
substances. 1 Itching is also a common symptom of dry 
skin conditions such as eczema or dermatitis. In the winter, 
these conditions tend to get worse due to the cold harsh 
weather conditions and factors such as central heating. 

Eurax relieves the itching and irritation caused by 1 
different skin conditions: 

Allergic rashes 
Insect bites and stings 

Nettle rash 
Heat rash 

Personal itching 

Why recommend Eurax? 

Eurax is suitable for use by adults and children from three 
years and it is available as a cream and a lotion. Eurax: 

Works quickly and effectively 

Relieves itching and skin irritation 

Soothes and moisturises the skin 

Provides relief for up to 10 hours 

For more information contact the PL holder: 
Novartis Consumer 
01403 218111 


To stop that itch 

1 . Institution of Occupational Safety and Health, 2007 

EURAX® CREAM / EURAX" LOTION Presentations: Cream or Lotion containing crotamiton BP 10% w/w Indications 
Relief of itching and skin irritation due to e g sunburn, dry eczema, itchy dermatitis, allergic rashes, hives, nettle rash, 
chickenpox, insect bites and stings, heat rashes and personal itching Also used as a treatment for scabies (acaricide) 
Legal Category GSL Further information is available from Novartis Consumer Health, Horsham, RHI2 5A8, UK 

28.08.10 13 

Contact us 

• Email your letters, including your name, address and contact 
number, to 

— ^ 




Mutton dressed as lamb 

I heard on the news that insurance fraud is on the 
increase. I suppose that as work dries up, people turn to 
whatever they can think of to bring in money, and 
necessity is not always the mother of a good invention. 
But a big company can't burn its factories and make a 
claim, so what's a multinational to do when times are 
hard? Let me tell you a story. 

There was an old Victorian pharmacy called Ye Olde 
Penny Dreadful that produced its own Cold Cure and 
Cod Liver Oil. These were marketed so well that by the 
late 19th century, Penny Dreadful Cold Cure and Penny 
Dreadful Cod Liver Oil were on the shelves of every 
pharmacy and supermarket in the country. 

These products had become market leaders, but 
shareholders of Ye Olde Penny Dreadful pic were 
demanding ever greater profits. This was a problem 
because they had saturated the market, and couldn't 
make people buy any more Cold Cure or Cod Liver Oil. 
They couldn't patent a brand new treatment because, 
well, everything easy has been invented and besides - 
it takes too long and costs too much money. So what 
is a cheap and quick way of making money? Market 
your old product in a new way. Or in other words - 
range extension. 


So they started with New - Full Strength Cold Cure 
and Single Dose Cod Liver Oil, which they said appealed 
to a younger market, and so the advertising showed 
people with iPods taking Penny Dreadful Full Strength, 
or skateboarders using Penny Dreadful Single Dose CLO 
to keep their knees supple. It sold well. Retailers smiled, 
Penny Dreadful pic smiled, and everyone was happy. 

The following year they introduced Junior Cold Cure 
as well as Cod Liver Oil "with Multivitamins", "with 
Orange and Mango", and "with Probiotics". Of course, 
with each extension to the range there was big press 
and TV advertising of these "new" products. Having 
created such a demand, they then sold millions of cases 
to the wholesalers, who in turn sold them to the poor 
pharmacists who had to stock it, and at last count there 
were 50 lines in the Penny Dreadful range. By now 
pharmacy had space for nothing else on the shelves. 

And the moral of this story? There's only so many 
range extensions you can bring out before retailers will 
rebel against this lazy form of business, because the 
public are only going to spend their diminishing 
disposable income on something genuinely new. 

And you must engage with pharmacy to develop a 
new market, which at least is what Teva looks to be 
doing (C+D, August 21, p14). They are hoping to 
persuade the public to "trade down" from the premium 
product to generic, and it might just work, since the 
only high street stores seeing record increases at the 
moment are the pound shops. If we can only find some 
shelf space... 

Are there too many product 
range extensions? 





14 Chemist Druggist 28.08.10 

What do you think? 

Medicine adherence - just a phone call away 

Ever had this experience: you buy a 
new camera, smartphone or other 
piece of technology and, a couple of 
weeks later, you still can't make it do 
some of the things you want It is 
really frustrating, and you get a bit 
fed up with it. Now, imagine that the 
person who provides you with this 
technology contacts you a couple of 
weeks later and says: "How are you 
getting on 7 Have you got any 
problems? Here is how to make it do 
what you want." Would you buy 
from them again? I bet you would 
Some of us, cash-rich and time-poor, 
would probably pay for the advice 

So why don't you do it with the 
medicines you dispense 7 

Some years ago I had been 
working with specialists in the 
usability of technology, studying 
computerised dispensing systems, 
when it finally struck me - in a 
Homer Simpson-like 'D'oh' moment 
- that medicines are technologies, 
too, and that perhaps a significant 

part of non-adherence was a 
usability issue. I pulled together a 
team, and we showed that many 
patients struggled with medicines 
soon after starting on them 

We found that, in patients who 
had just started a new medicine for 
a chronic condition, a phone call 
from a pharmacist after a couple of 
weeks was immensely helpful. Non- 
adherence was halved, and the 
number of reported problems was 
significantly reduced; and all for a 
phone call, which lasted an average 
of only 12 minutes Even better, 
when we followed up patients for 
several months and conducted an 
economic analysis we found that 
this new service was more than 90 
per cent certain to be more cost- 
effective than normal care. 

Now, as an academic, I am of 
course officially useless. So I was 
delighted when this research 
became a recommendation in 
2008's pharmacy white paper. I was 

even more delighted when I found 
that funding negotiations were in 
progress. I was not sure whether this 
would be scuppered by the new 
government; however, at a reception 
at the House of Lords, Earl Howe 
specifically mentioned this work as 
something they would look at 
continuing. The recent report in C+D 
(July 24/31, p14) suggests that the 
service may be funded. 

What I remember most about the 
service is how powerfully some 
simple suggestions and information 
affected patients' lives. It was really 
fulfilling for the pharmacists, as well. 
Surprisingly few patients start a new 
medicine for a chronic condition, 
perhaps one or two a day at a typical 
pharmacy. I hope many of you will 
take up this new service; I do not 
think you will regret it. 
Professor Nick Barber, Centre for 
Medication Safety and Service 
Quality, The School of Pharmacy, 
University of London 


Victorian parallels 

Like many pharmacists I have 
watched with interest the 
endeavours of Professor Nick Barber 
in BBC2's Victorian Pharmacy 
show. The feeling I take away from 
each episode is inevitably a sense 
of pride, but also wonder at the 
journey of the profession. 

Interestingly, the number of 
parallels that exist today also 
impress - regulation vs professional 
freedom; the role of pharmacists in 
public health and in championing 

Email your letters to haveyour 

the needs of those who cannot or 
choose not to access a doctor. 

My pharmacy was established in 
1790, 40 years before the setting of 
the first programme. I can't help but 
feel that pharmacy is less interesting 
than in the days of wet chemistry 
and firework-making! 

The interesting part of the 
programme for me is in the direct 
comparisons to modern pharmacy, 
in particular the role that pharmacy 
played in developing the first 

antiseptics. When ordinary people 
could not afford to access a doctor it 
was pharmacy to which they turned 
for health advice. The direct parallel 
these days is to people who are not 
registered with a CP, who will be 
completely disenfranchised by GP 
commissioning - it is this group that 
pharmacy should be in a position to 

Public health is another key area 
where the Victorian pharmacist lit 
the way - improving sanitation; 
getting people to stop smoking, eat 
less, exercise more and drink less - 
and there is something very 
Victorian in those values. 
Interestingly, Anna Dixon, head of 
policy at the King's Fund, recently 

noted that GPs have largely failed 
to address health inequalities in 
favour of achieving QOF points. 

This will become a key territory 
under GP commissioning 
arrangements as GPs will not 
control the public health budget - 
being cynical you could read this as 
extra money for GPs as it may sit 
outside of their budgets. However, 
pharmacy has walk-in convenience 
up its sleeve on this issue. 

We cannot allow government to 
see general practice as the panacea 
for public health - pharmacy has 
just as important a role, and sees 
many more people every year. 
Mike Hewitson, Beaminster 
Pharmacy, Dorset 

From the moment your pharmacy is connected to our enhanced, intuitive PMR system with its future-proof design, you 

are connected to a better future. So, with the demands being made on you by the current National Programmes, get better 
connected today. Call your ProScript LINK Account Manager, email or visit 

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16 Sip feeds r 19 MUR ethics ^ 20 Injury and illness ^ 22 Dispensing errors ^ 25 Retirement 


Your weekly CPD revision guide 

60-second \ S 
summary /sL^ 

Why read this article? 

A range of oral nutritional supplements 
(ONS) is available. However, ONS 
cannot be treated as simple foodstuffs, as 
they can affect the pharmacology of drug 
treatments and there may be interactions. 
Patients who do not require their ONS or 
dislike the flavours prescribed may 
stockpile the products, and alternatives 
may be indicated. 

How widely do ONS 
products vary? 

ONS vary widely in composition; some 
are nutritionally complete, others are in a 
concentrated form suitable for patients 
able to swallow small amounts only, 
while Others are high in micronutrients or 
contain fibre. As well as varieties of 
flavours, ONS products are available with 
a selection of textures, which can help 
reduce taste fatigue. Pre-digested ONS 
products may be suggested for 
individuals with maldigestive states. 

What are the issues in 
dispensing ONS? 

Patients are likely to be taking other 
medicines so interactions need to be 
considered. Pharmacological interactions 
with ONS are varied, and can include the 
effects that the ONS may have on other 
ications and vice versa. 


Supported by 

ailed to you each week, 
CPD newsletter at 


Adult oral sip 

A community pharmacist's guide to ONS products 

Peter Austin MRPharmS 

What is malnutrition and why take an interest in 
it? The 2006 Nice adult nutrition support 
guidelines define an adult who is malnourished or 
who is at risk of malnutrition. The criteria (see 
table 1, below right) are based on those of the 
Malnutrition Universal Screening Tool. Obese 
patients may be either malnourished or at risk of 
malnutrition within these criteria. 

Many individuals with a poor nutritional state 
will be elderly and/or have co-morbidities. Around 
10 per cent of free-living and 30 to 40 per cent of 
elderly patients in care homes will have, or be at 
risk of, malnutrition. 

A poor nutritional state resulting from 
inadequate intake by any route can lead to 
complications, and nutrient deficiencies lead to 
functional compromises that may not be 
immediately obvious (see table 2, opposite page). 
In addition, the indirect consequences of these 
various complications and compromises limit the 
individual's ability to effectively deal with other 
co-morbidities they may have. 

The importance of nutritional state to clinical 
outcome, and the significant annual expenditure 
on nutrition products, means that this is an area of 
interest to all pharmacists. 

Use of sip supplements 

Oral nutritional supplements (ONS) are used to 
improve the nutritional intake of patients who 
have a safe swallow but who are unable to meet 
their needs from a normal or otherwise 
supplemented diet. ONS should be continued 
until the patient can demonstrate an adequate 
intake from normal food. Their use is typically 
short term (weeks to months) but there may be 
cases where they are required for much more 
extended periods. Sip supplements would not 
usually be expected to be the sole source of 
nutrition and therefore the concurrent use of ONS 
with other nutritional intake is perfectly 
acceptable to meet the overall needs of the patient. 

- • ■ : ■ ■ ..v ■ 

The most obvious variation in ONS is the 
nutritional completeness of the product. This is 
relevant because the provision of protein and 
energy alone does not meet the complete 
nutrient requirement for cellular growth and 

repair, so in some cases an improvement in body 
function could be expected without an associated 
improvement in weight gain. A 'complete' sip feed 
contains a full range of nutrients that would, in 
theory, be able to effectively provide an 
individual's complete nutritional requirement. The 
volume required depends on the specific ONS 
content per unit volume and on the requirements 
of the patient. 

A wide range of ONS is available, including 
those that are 'complete' at a lower volume. These 
are used for patients with a more limited fluid 
requirement, or who are unable to tolerate higher 
volumes of ONS but can ensure an adequate 
intake of fluid from another source if necessary. 
Other ONS may, for example, have a greater 
micronutrient content per unit volume, or contain 
fibre to meet different clinical needs. 

Complete ONS have a fat component that 
provides essential fatty acids. Some patients find 
this type of supplement more palatable if diluted 
with milk immediately before consumption or if 
they are used in a variety of recipes - they can, for 
example, often be mixed with coffee or included in 
cakes. A variety of recipes is available from the 
manufacturers. As well as a variety of flavours, the 
texture of ONS can offer a further variation to limit 
taste fatigue, such as a tangy yoghurt-style. 

The fat component of ONS is sometimes 
replaced with a greater carbohydrate component 

Table 1 : Nice adult 
malnutrition definitions 


Body mass index (BMI = kg/m 2 ) of less 
than 18.5, or 

BMI of less than 20 with unintentional 
weight loss of more than 5 per cent over the 
preceding three to six months, or 

Unintentional weight loss of more than 
10 per cent over the preceding three to six 

At risk of malnutrition 

More than five days with a poor nutritional 
intake, or 

• Specific nutritional needs due to poor 
absorption, high losses or increased needs 

Note: definitions should always be considered 
in clinical context 


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Table 2: Effects of malnutrition 

More obvious effects 

® Poor vision (vitamin A deficiency) 

• Scurvy (vitamin C deficiency) 

• Brittle skeleton (electrolyte and 
micronutrient deficiencies eg vitamin D) 
■ : Mobility (muscle weakness) 

Less obvious effects 

• Poor wound healing (creation of new cells) 
Poor immune function 

Decreased cardiac output (functional 
muscle compromise) 

Poorer ventilation and hypoxic responses 
(functional muscle compromise) 

Secondary anorexia (possibly due to 
micronutrient deficiencies) 

so that it becomes a juice-based supplement. 
While these are technically 'incomplete' due to the 
lack of essential fatty acids, they are also 
potentially more palatable to some patients. 
However, they can be very sweet-tasting and may 
require dilution with water immediately prior to 
consumption in a similar manner to diluting a fruit 
squash. It is possible that prolonged consumption 
of juice-based supplements without an alternative 
source of essential fatty acids could lead to 
essential fatty acid deficiency, which may present 
as dry, fragile, flaking skin. 

Pre-digested or elemental supplements are 
suggested to be of potential benefit for individuals 
with maldigestive states (eg pancreatic disease), 
but they can worsen symptoms in malabsorptive 
states due to the osmotic effect resulting from 
their high osmolality. 

Sodium-supplemented sip feeds are not 
commercially available (and so are unlicensed), but 
may be of benefit to patients with a high output 
small bowel stoma who can readily become salt 
(and water) depleted. This treatment should always 
be undertaken under the care of a specialist; a 
sodium chloride injection may be added into the 
sip feed of these patients immediately before 
consumption to give a final sodium concentration 
of between 100 and 120mmol per litre. 

ONS with a minimal composition are also 
available that provide only a single or limited 
number of nutrients. These products are unlikely 
meet a nutritional deficit without an alternative 
source of the missing nutrients because they are 
incomplete, and should be used only with 
specialist advice and regular review. 

Most ONS are gluten-free and suitable for 
patients with coeliac disease, but it is worth 
checking in individual cases to limit avoidable 
steatorrhoea. Most prescribable ONS are also 
lactose-free, but again, it is worth checking in 
individual cases. 

Sip supplement interactions 

Patients prescribed ONS are also likely to have 
co-morbidities and/or be taking other medicines, 
whether prescribed or not. This means physical 
and pharmacological interactions need to be 
considered to ensure the safe and effective use 
of ONS. 

Precipitation within the gastrointestinal tract of 

ONS with other concurrently administered 
medicines will limit the absorption of both the 
ONS and the interacting medicine, preventing the 
full intended benefits of each treatment. ONS can 
interact to form a precipitate with medicines that: 
o are primarily an electrolyte source (eg calcium 
tablets or effervescent potassium) 
• contain electrolytes (eg antacids) 
® may precipitate with either milk or electrolytes 
(eg tetracyclines). 

Interactions may be very significant, for example 
if electrolyte precipitation occurs with ONS this is 
likely to limit the intended supplementation effect. 
It is therefore important to advise the separation of 
ONS from physically-interacting medicines, 
especially as individuals may gradually sip an ONS 
rather than drink the whole supplement at once, 
effectively prolonging the duration of ONS 
administration. Ideally administration of ONS and 
an interacting medicine should be separated by 
two hours. This may be reduced to one hour if the 
interaction is less critical (with adequate 
monitoring), but a longer window may be required 
if the patient has gastroparesis and/or some other 
form of gastrointestinal dysmotility. 

In some cases, the dose of an interacting 
medicine may need to be increased to limit the risk 
of poor absorption. 

ONS may affect control of blood sugar levels, 
especially in diabetic patients, and particularly with 
juice-based supplements due to their greater 
carbohydrate component (which is mostly 
partially hydrolysed starch). The effect of ONS on 
good blood glucose control may require specialist 
adjustment of anti-diabetic medicines. 

ONS may contain vitamin K, and while this is 
often included in only a very limited quantity, in 
principle it is a warfarin antagonist and could 
therefore affect an individual's INR, requiring 
careful monitoring and, if necessary, adjustment of 
warfarin dosing. 

Individuals with pancreatic insufficiency who 
require pancreatic enzyme replacement to assist 
with digestion and subsequent absorption of their 
diet may also require enzyme replacement for 
standard ONS, typically 10,000 units per standard 
complete or juice-based sip feed. Pre-digested or 
elemental ONS are much less likely to require 
concurrent enzyme replacement in these patients 
to ensure adequate absorption and an appropriate 
stool consistency, because the action of the 
enzymes becomes less relevant. 

Sip supplement prescriptions 

ONS are usually recommended by a specialist 
who is often, but not always, a dietitian, or are 
prescribed by a CP. Despite this, pharmacists have 
a valuable role to play in their appropriate use (see 
table 3, above right). 

Prescribers should confirm the prescription 
complies with these recommendations by using 
the endorsement 'ACBS' on the prescription. If 
this endorsement is missing, the pharmacist 

Table 3: Tips for pharmacists 

Patients with unintended weight loss 
associated with poor nutritional intake should 
be referred to the GP or a dietitian for a 
nutritional review. 

With repeat prescriptions for sip feeds, 
check with the patient how they find their 
supplements and whether they have any 
adverse reactions (eg loose stools). Poor 
compliance or malabsorption indicates the 
need for a referral to the CP or a dietitian as 
appropriate. This is in order to ensure both 
adequate and effective nutritional intake and 
to avoid stockpiling of unused supplements. 

Offering a range of flavours and/or textures 
of ONS may prevent taste fatigue. 

Milky-type sip feeds can usually be diluted 
with milk, and juice-based sip feeds can usually 
be diluted with water immediately prior to use 
in order to improve palatability. Recipes may 
also be available from the manufacturer. 

Sip feeds are usually more palatable chilled. 

Watch out for dry, fragile, flaking skin with 
prolonged use of 'juice-based' sip feeds, as this 
indicates referral to the CP. 

Consider physical and pharmacological 
interactions of sip supplements with both 
other medicines and co-morbidities. 

Contact the prescriber if the 'ACBS' 
endorsement is missing from prescriptions to 
clarify whether this is intentional. While 
prescription payment does not depend on this, 
it is a courtesy that will likely support the 
pharmacist-prescriber relationship. 

should not add it and will still receive payment 
following dispensing. However, the prescriber may 
have to justify the cost of the prescription to their 
PCT as it could be taken to be for an unapproved 

Unless specified, a variety of flavours can be 
supplied depending on the patient's preference, 
and a dispensing fee for each one can be claimed. 

Some patients do not require, or do not take, all 
of their prescribed supplements, for example due 
to taste fatigue or a change in clinical condition. 
This may lead to 'stockpiling' of prescribed ONS, 
for which a clinical review is indicated. 
Further reading and a table of ONS indications is 
available in the full version of this article online at 

Peter Austin is a senior pharmacist at 
Southampton University Hospitals NHS 

Download a CPD log sheet that helps you 
complete your CPD entry when you 
successfully complete the 5 Minute Test for 
this Update article online (p18). 







16 Sip feeds ^ 19 MUR ethics ^ 20 Injury and illness ^ 22 Dispensing 



r 25 Retirement 

Adult oral sip supplements 

What are the criteria for defining malnutrition and 
those at risk of malnutrition? What considerations 
should be taken into account when prescribing juice 
based supplements? Which medicines might interact 
with oral nutritional supplements (ONS)? 

This article describes ONS and includes information 
about malnutrition, the use of sip supplements and 
the types available. It also discusses interactions with 
other medicines, prescribing and useful tips for 

Find out more about the factors affecting 
malnutrition in the elderly from the 
website at 

• Find out more about the Malnutrition Universal 
Screening Tool from the British Association for Parenteral 
and Enteral Nutrition at 

Read about nutritional support in primary care on the 
Patient UK website at 

Revise your knowledge of the range of ONS available 
by reading Appendix 7 Borderline substances in the BNF. 

Review any patients you have who regularly use ONS, 
thinking about how you could improve the services you 
provide. Identify those who might benefit from an MUR. 

Are you now familiar with malnutrition and oral 
nutritional supplements? Do you know who they are 
suitable for and what interactions you should be aware 
of? Could you give advice about them to your patients? 

5 minute test 
What have you learned? 

Test yourself in three easy steps: 

Step 1 

Register for Update 2010 and receive a unique PIN number 

Step 2 

Access the 5 Minute Test questions on the C+D website at 

Step 3 

Use your PIN to complete the assessment online. Your test score will be 
recorded. If you successfully complete the 5 Minute Test online, you wilt 
be able to download a CPD log sheet that helps you complete your CPD 
entry at 

Registering for Update 2010 costs £37.60 (inc VAT) and can be done easily 
at or by calling 0207 921 8425. 

Signing up also ensures that C+D's weekly Update article is delivered 
directly to your inbox free every week with C+D's email newsletter. 

Get a CPD log sheet for your portfolio when you successfully complete 
the 5 Minute Test online. 

Practical Approach 

What's causing pain around the eyes? 

At the Update Pharmacy a woman 
has asked to speak to the pharmacist 
and has been referred to David 
Spencer, who sees her in the 
consultation area. David asks how 
he can help. 

"Basically, I want something for 
this nasty pain I've had around here 
for the last couple of days," the 
woman says, passing her fingers 
across her forehead between her 
eyebrows and beneath her eye 

"Did it just start like that?" David 


"Well, that's not the whole story, 
I suppose," the woman replies. "I 
had a nasty cold about a week ago. 
I thought it had cleared up. I 
had a runny nose, but it stopped. 
Then it started to feel blocked 
up, the catarrh came back, but 
thick this time, and the pain 

"Is the catarrh clear, or coloured at 
all?" David asks. 

"It's a nasty, yucky yellow." 

"Oh," David says, "in that case I 
think you need to see your doctor." 

"That's why I've come here," 
the woman replies. "I phoned up 
for an appointment, but the 
receptionist said that it didn't sound 
urgent and they couldn't fit me in for 
three days." 

"I think that you're still going to 
need to see your doctor," David 
replies, "but in the meantime I can 
recommend something to ease your 


1. What is the condition the 
woman is suffering from? 

2. What are the characteristic 

3 What is the cause? 

4. Why will the woman need to 
see her doctor? 

5. What are the features that 
might distinguish the condition 
this woman is suffering from its 
more trivial form? 

6. What can David recommend to 
ease the symptoms? 

7. What signs or symptoms would 
cause David to make urgent 
referral to the doctor? 


1. Acute rhinosinusitis, inflammation 
of one or more of the paranasal 

2. Nasal blockage or congestion; 
discharge or postnasal drip; facial 
pain or pressure; reduction or loss of 

3. Common cold viruses cause 
mucosal swelling and obstruct the 
sinus openings into the nose. 
Symptoms result from increased 
mucus production, reduced drainage, 
ciliary paralysis, and stasis of 

4. Secondary bacterial infection 
has occurred and will need to be 
treated with a course of antibiotic. 

5. Duration longer than seven 
days; purulent green or yellow 

nasal discharge; history of 
improvement, then deterioration in 
symptoms; fever and general 
malaise; facial pain and tenderness, 
particularly if unilateral or 

6. Steam inhalations to help 
liquefy mucus; analgesics; 
decongestants: oral 
(pseudophedrine, phenylephrine), 
topical (oxymetazoline, 
xylometazoline, phenylephrine, 

7. Eye redness, swelling or other 
apparent eye abnormality; neck 
stiffness, drowsiness, photophobia, 
severe generalised headache, visual 
disturbance, unsteadiness. 

Lindbaek M, Hjortdahl P. The clinical 
diagnosis of acute purulent sinusitis 
in general practice - a review. Br J 
Gen Pract 2002;52:491-5. 

Got an idea for a Practical 
Approach scenario or would you 
like to write one? Email your 
suggestion to: haveyoursay@ 

18 Chemist Druggist 28.08.10 




^ 16 Sip feeds ▼ 19 MUR ethics f 20 Injury and illness f 22 Dispensing errors If 25 Retirement 

This series aims to help you make the right decisions when confronted by an ethical dilemma. Every month we present a scenario likely to arise in a 
community pharmacy and ask a practising pharmacist and/or a member of the Pharmacy Law and Ethics Association (PLEA) to comment on the legal and 
ethical implications of the actions open to you. Readers are invited to have their say at 

Can you take the 
'easy' route to MURs? 

he NHS contract in England and Wales 
allows pharmacy contractors to claim for 
a maximum of 400 MURs per year. At 
£28 per review this can represent considerable 
income. The aim of payment for these reviews is 
to enable patients to get the best from their 
medication by establishing dialogue with both the 
patient and their CP. 

The NHS provides a service specification and 
while the proposal under consideration is not 
outside the framework, this 'cherry picking' 
approach is not quite what the NHS had in mind 
as a more clinical role for pharmacists. 

JbUilCCll COlaSluGIuuOllS 

Pharmacists are required to be honest and 
trustworthy (Principle 6 of the Code of Ethics) and 
comply with legal, and in this case contractual, 
requirements. Their judgement is also expected 
to not be impaired by commercial interests 
(Principle 2.2). Choosing only 'easy' reviews 

CPD Reflect • Plan • Act • Evaluate 

could be seen as being influenced by financial 

According to the Code of Ethics, registration as 
a pharmacist requires you to use your skills to 
benefit service users, maintain good professional 
relationships and promote trust and confidence. 
In this situation, making the care of patients your 
first concern (Principle 1) would require 
pharmacists to prioritise time for those patients 
who would benefit most from an MUR. In 
particular, principles 1.5 and 1.6 concern 
requirements to ensure the effective use of 
clinically appropriate medicines. 

The fact that there is a contractual agreement 
in place does not absolve a pharmacist from the 
need to ensure that the patient is treated 

Choosing 'easy' targets might not show the 
profession in a good light. 

Ruth Rodgers MRPharmS PhD BPharm Hons is 
a senior/clinical lecturer in pharmacy practice, 
Medway School of Pharmacy, Universities of 
Kent and Greenwich 

The criteria for providing MURs as an advanced 
pharmaceutical service in England are contained 
within The Pharmaceutical Services (Advanced 
and Enhanced Services - England) Directions 
2005, which can be found at Part VIC of the 
Drug Tariff. 

The Directions state that patients are only 
eligible for MURs if they have been receiving 
pharmaceutical services from the pharmacy for a 
period of at least three consecutive months and 
have not had an MUR in the preceding 12 months 
(except in limited circumstances). 

PCTs may notify pharmacists in their area of the 
categories of patients who may benefit from an 
MUR, but there is nothing to prevent pharmacists 
from offering MURs to patients in other 

While there has been some discussion in the 
pharmacy press about the targeting of MURs, the 
Directions have not been changed so far. 
Noel Wardle is a solicitor at Charles Russell 
LLP, specialists in pharmacy law 

More dilemmas are online at www.chemist 


PLEA is an association of 
pharmacists interested in 
law and ethics, and lawyers 
or ethicists specialising in 
pharmacy, with the aim of promoting 
understanding of the ethical basis for 
professional judgement 

28.08.10 Chemist Druggist 19 






16 Sip feeds 4 19 MUR ethics 20 Injury and illness 22 Dispensing errors |> 25 Retirement 

Health and wellbeing at work is important for both employees and pharmacy businesses - without healthy, happy staff, customer service is likely to 
suffer. This is the fifth in C+D's monthly series of guides and tips on improving your wellbeing, which is covering topics from establishing a work-life 
balance to preventing crime in your pharmacy. If there is a health and wellbeing issue you would like us to cover, email 


Avoiding injury and illness 

Emma Wilkinson looks at simple steps pharmacists and employers can take to 
cut the risk of repetitive strain injury (RSI) and other work-related illnesses 

sore back from being on your feet all 
day, eye strain from reading 
bureaucratic small print, tension 
headache from being overworked: any of these 
sound familiar? All are workplace-related injuries 
or illnesses that pharmacists are at risk of. For 
the purposes of data collection the Health and 
Safety Executive (HSE) classes community 
pharmacy as a retail business, and figures show 
that in this category reported injuries have fallen 
over the past decade and work-related ill health 
is lower than in other industries. 

That said, in 2008-09, the Labour Force Survey 
showed that an estimated 3.1 million working 
days were lost in the retail sector due to 
workplace injury and work-related ill health. 

Although there are no specific figures for 
pharmacy, the types of work-related illness and 
injury that pharmacists are at risk of are pretty 
clear. And most are things a pharmacist might 
well pick up in patients - but possibly overlook in 
themselves and their staff. 

Musculoskeletal disorders, which include lower 
back pain, joint pain and RSI, are the most 
common workplace-related illnesses - yet there 
are simple ways to prevent them and to stop 
them getting worse in staff who already have 
these problems. 

When it comes to back pain, whether work- 
related or a pre-existing condition, the HSE 
recommends: trying to take regular breaks; if 
sitting, making sure your chair is comfortable and 
supports your back; to get up and stretch; and to 
vary your tasks as much as possible so you are 
not doing the same movements for prolonged 
periods of time. 

RSI or, to use the medically correct term, upper 
limb disorder, basically means any kind of 
tenderness, aches and pain, stiffness or numbness 
in the arms, shoulders or neck. 

Often made worse by work, these injuries 
plague those who find themselves doing the 
same manoeuvre over and over, such as using a 
computer mouse or typing. 

Uncomfortable working postures or working in 
an awkward position and poor working 
environment and organisation, such as bad 
lighting, work pressure or lack of breaks, can also 
contribute to these sorts of strains. 

It is also important to point out that 
organisational factors such as high workloads, 

tight deadlines, and lack of control of the work 
can increase the risk of back or upper limb 
problems because stress can cause more tension 
in the muscles. 

According to the NHS, one in 50 workers in the 
UK has reported some sort of RSI and a diagnosis 
cannot always be made. Carpal tunnel syndrome, 
tendonitis and writer's cramp are among the 
conditions that can occur or be made worse by 
work, often through use of computers. 

The key with RSI is to get treatment as soon as 
possible because, although initially the symptoms 
may only happen while carrying out certain tasks 

5 key 

warning signs 

There may be problems in your pharmacy if 
you notice that staff: 

' tI Take more time off for illness 

2 Report more injuries or pain and 
discomfort in the upper limbs 

3 V Modify their workstations or the tools 
they use 

''^L Appear reluctant to perform 
particular tasks 

Wear bandages or splints 

at work and ease off once relaxing at home, it can 
become more permanent and even irreversible. 

It is common for the problem to develop over a 
long period of time and pharmacists should be 
quick to act if they have any symptoms. 

Your employer has a responsibility to perform risk 
assessments and put in place reasonable 
measures to reduce that risk as well as acting on 
any reports of ill health caused by work. 

This includes a legal duty to try to prevent 
work-related RSI and ensure that anyone who 
already has the condition does not get any worse. 

RPSCB president Steve Churton says: 
"Employers are responsible for the safety of their 
staff and we expect them to ensure that the 
working environment is as safe as possible so their 
staff can carry out their duties without injury. 

"This includes providing the correct equipment 
needed for the job and the relevant training and 
support to use it correctly." 

John Evans, superintendent pharmacist at Asda, 
adds that he is not aware of any specific issues 
on work-related illnesses raised by Asda 
pharmacists, but the company has taken several 
steps in recent years to make the working 
environment more comfortable. This has included 
improving the lighting and adjusting the height of 
the dispensing benches. 

One issue that all pharmacists face, he says, is 
being on their feet for the long shifts. "Any 
pharmacist will tell you that being on your feet all 
day really hurts - you get leg ache and back ache 
but you do get used to it. 

"We found during visits to a number of our 
stores that they had put mats underneath the 
computer area which were softer on the feet. 

"Pharmacists found that their legs didn't ache 
as much so we now offer them to stores that 
want them." 

When it comes to using computer equipment, 
RSI is not the only risk. Eye strain can also be 
a problem and pharmacists have the extra 
challenge of having to read small print on 
medicines. Good lighting is important in general 
but there are specific regulations covering use of 
'display screen equipment'. Once more the onus is 
on employers to safeguard their staff and one of 
the requirements is that they provide eye tests on 
request as well as information and training. 


Drueeist 28.08.10 

Get CPD resources straight to your inbox 

Martin Crisp, superintendent pharmacist at Superdrug, says the multiple is 
just embarking on a project to make sure the working environment is as 
supportive for pharmacists as possible 

"We're looking at things like the mats, monitors, lighting - making things 
more economically friendly 

"One of the things we did a couple of years back was to put all the 
monitors at eye height, which made a big difference. 

"It's often the little things that can really help and we hope to be finalising 
the project next year." 

He said one reason for reviewing this now was that more and more 
equipment was becoming available to prevent work-related injuries and 

For independent pharmacies there is a wealth of advice on the HSE website 
on protecting your staff, including how to make sure you are complying with 
the law and also how to carry out risk assessments. 

One key publication for independent pharmacies, which perhaps do not 
have access to the occupational health facilities of larger companies, is a 
booklet designed to help employers and managers in small businesses to 
understand upper limb disorders. This can be downloaded at 
uk/pubns/indg1 71.pdf. 

An NPA spokesperson points out that prolonged periods of work at a 
computer without a break may increase the likelihood of visual, physical, 
mental fatigue and work-related upper limb disorders and stresses the 
importance of regular breaks. 

He says that, for any health and safety issue, pharmacists can call the NPA 
Employment Advisory Service Helpline - 24 hours a day, Monday to Sunday. 
The NPA is also planning to publish some advice in the coming weeks on 
reducing workplace stress - another factor in workplace-related illness 
leading to tension headaches among other symptoms. 

"Preventing stress occurring is far easier than dealing with the 
consequences and it is important that the whole organisation is involved in 
the processes of identifying issues and dealing with them immediately," the 
NPA advises. 

CPD Reflect • Plan • Act • Evaluate 

Tips for your CPD entry on workplace injury and illness 

REFLECT Am I aware of my and my staff's risk of workplace injury 
and illness? 

PLAN Assess my and my staff's working environments. 

ACT Implement necessary changes to reduce the risk of injury 

and illness. 

EVALUATE Is the working environment safer and more comfortable? 





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28.08.10 21 




16 Sip feeds 19 MUR ethics \ 20 Injury and illness 22 Dispensing errors 25 Retirement 

The new community pharmacy think-tank 

After C+D readers 
unanimously voted for the 
Elizabeth Lee case to be 
discussed by the C+D Senate 
the Senators assess how 
much protection the CPS 
guidance on dispensing error 
cases will bring and what the 
profession needs to do next. 
Zoe Smeaton reports 

We must do everything in our power to stamp out 
errors instead of writing moaning letters, the C+D 
Senate hears 

Angela Chalmers Pharmacist, Boots 
Debby Crockford Area manager, 
Rowlands Pharmacy 

Hilary D'Cruz Partner, Ansons Solicitors 

Andrew Derham Commercial and supply 

chain manager, AstraZeneca 

Ian Facer Chairman, NPA 

Max Gosney News editor, C+D 

Keith Howell Pharmacy manager, 

Delmergate Pharmacy, Kent 

Peter Kelly National sales manager, 


Mark Koziol Chairman, Pharmacists' 

Defence Association 

Nick Lowen Director of commercial 

operations, GlaxoSmithKline 

Gary Paragpuri Editor, C+D 

Steve Poutton Director of commercial 

operations, Pfizer 

Partner and head of 
healthcare, Charles Russell 
Zoe Smeaton Senior reporter, C+D 

Does the CPS guidance make 
any difference? 

David Reissner: "I think it's designed to make 
prosecutors think twice before prosecuting for a 
single dispensing error but it's obviously hugely 
disappointing because it doesn't do that. All the 
CPS [Crown Prosecution Service] has done is 
restate the code for deciding whether to 
prosecute or not. But that code was in place at the 
time Elizabeth Lee was charged. If prosecutors 
now were brought under pressure by families or 
by police there is no reason to suppose the 
situation would be particularly different." 
Keith Howell: "As a pharmacist I don't feel any 
more protected. Looking at the CPS's original 
advice you would think that it would protect us 
anyway - it's difficult to see how prosecuting 
Elizabeth Lee was in the public interest given that 
she had a previously unblemished record and had 
made a genuine mistake. I suppose there is some 
protection but I just don't feel it - it feels like we 
are exposed." 

Angela Chalmers: "I don't feel reassured by the 
guidance, either, and I don't feel protected. I just 
do all I can on a day-to-day basis to prevent 
something leaving my pharmacy in error." 
Ian Facer: "As someone who is practising, I do feel 
a little happier that we perhaps have a little more 
protection than before, but clearly it doesn't go 
far enough." 

Mark Koziol: "I actually think that although they 
still don't answer the main question, it gives a lot 
more for defence teams to get their teeth around. 
For example, it says that if the healthcare 
regulator has indicated it will take action or even 
might do so in the future then that could be used 
as an argument against prosecution being in the 

public interest. Defence lawyers should be able to 
use tools like that far more effectively now." 
Hilary D'Cruz: "I agree the guidance opens some 
doors. There is now the opportunity to look at the 
public interest part. It also opens the door to bring 
in the pharmacy professional bodies to get their 
guidance and find out whether disciplinary action 
is going to be taken." 

Mark Koziol: "And there is a section in there that 
says the Medicines Act will be reviewed and will 
be looked at with a view to decriminalising 
dispensing errors - that's a powerful message 
that sets the mood music. Unfortunately, that 
could be very different to the feeling when 
someone has died, a pharmacist is sitting in the 
cells and the police are absolutely determined to 
get their guy." 

David Reissner: "The prosecution is entitled to 
look at the impact on the victim and the family of 
victim and take that into consideration, though. If 
the objective of the CPS guidance was to 
discourage prosecutions they could have come 
out more clearly and said so. The easy thing would 
have been to ask prosecutors to seek advice from 
the regulator, who has the expertise to determine 
what is a serious error and what isn't." 

Ian Facer: "I've got concerns about what the right 
solution should actually look like. We've got to be 
careful what it is we're actually asking for and at 
the moment I just wonder whether, given the 

22 Chemist Druggist 28.08.10 

Watch the Senators speak out on dispensing errors. Video interviews at 


experience we have got around the current 
Medicines Act, it might be better to try to firm up 
the guidance rather than messing with the Act 
[and decriminalising errors]." 
Hilary D'Cruz: "But the Medicines Act is under 
review and it would be safer for pharmacy to 
make sure that single dispensing errors are 
excluded from the law. Guidance is just that - 
guidance. In my view you've got to change the 
law. In the meantime your professional bodies 
need to lobby fiercely to ensure this guidance is 
used appropriately." 

David Reissner: "I think squeezing in 
parliamentary time for legislation changes is 
going to be quite difficult. We have a new 
government with quite a heavy legislation 
timetable so logistically it will be quite difficult to 
do. Instead I would make representations to the 
attorney general who is responsible for the CPS. 
I would say that this statement doesn't do the 
job and then say I wanted the CPS to say it 
wouldn't bring a prosecution without consulting 
the regulator." 

Do we need to look to the 
pharmacy profession to do 
more to prevent errors? 

Debby Crockford: "We need a culture in which 
we're not afraid to report errors. If humans are 
involved there are always going to be errors and 
the only way to improve practice is to self-report 
those. But pharmacists would be more comfortable 
doing that if errors were decriminalised." 
Angela Chalmers: "We also need to look at 
pharmacists' attitude to errors. Some are quite 
happy to sit and write moaning letters about it, 
but what are they doing about it as professionals? 
Are they taking responsibility for the fact that 
they can make errors and doing everything they 
can to minimise them 7 " 
David Reissner: "But you can't blame some 
pharmacists for not reporting. I dealt with a case 
recently in which an inspector had gone to a 
pharmacy after a report of a single error and asked 
to see the error log. They saw that the same 
locum over period of about two years had made 
18 errors and then the locum and the 
superintendent ended up in front of the 
disciplinary committee on allegations of 
misconduct. That sort of thing needs to change." 
Ian Facer: "I think there's a valid point on 
culture and how important patient safety is in 
what we do. It's going to be interesting because 
we're in an environment where we're going to be 
asked to do more for less, but there must come a 
point at which we can't do that and maintain 
patient safety." 

And can manufacturers do 
anything more with packaging 
to help reduce errors? 

Andrew Derham: "Packaging can help. With 
hospital tendering, for example, part of the 

Senators' top tips for reducing your error rates 

"We need to do more auditing. Reporting errors should be a positive thing used as a self-audit 
tool. As well as recording errors we should also be recording every time we avert an issue because 
we spot an error on a prescription, for example." 
Debby Crockford 

"The simple solution is to follow your SOP. If you get down to that and follow every single step 
properly, every time, errors won't happen. I did a patient safety review on every near miss we had 
made in January and I realised my dispenser had got complacent. So I printed out a copy of the 
SOP and asked her to think about all the steps she was forgetting. Since then she has gone from 
making seven errors a week to being unlucky if she makes one." 
Angela Chalmers 

"[Lack of] rest breaks are the silent killer. In lots of the error cases we deal with exhaustion is a 
very serious factor. We need to look at this as a profession." 
Mark Koziol 

process is us demonstrating how packaging is 
differentiated across a brand, to help avoid errors." 
Steve Poulton: "We have used the NPSA 
guidance in changing our packaging, so now it's 
not an exercise in corporate branding but in easy 
recognition and differentiation between streingths 
and commonly co-prescribed products." 
Nick Lowen: "It has to go beyond that too - there 
should always be research on that sort of thing 
even before drug names are agreed. It has to be an 
end-to-end process." 


The Senate Ruling 

1 . The CPS guidance is a step 
in the right direction, but 
doesn't go far enough. 

2. Prosecutors should consult 
the professional regulator 
before bringing any cases 
against pharmacists 
making errors. 

3. Changing the law might be a 
lengthy and difficult process. 

A. Pharmacists need to think 
about how they can help 
reduce errors. 

5. Extra regulation of 
packaging could help 
reduce errors. 




with yr actavis 

CPD Reflect • Plan • Act • Evaluate 

Tips for your CPD entry on reducing 
dispensing errors 

REFLECT How much do you focus on 

patient safety? 
PLAN How can you review safety and 

start learning from errors? 

ACT Implement a patient safety 

review and error-recording 
protocol, involving your staff. 

EVALUATE Has patient safety improved? 

Next week in C+D: The Senate 
delivers its verdict on how big 
pharma and pharmacists can 
work together more effectively 

28.08.10 Chemist Druggist 23 


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25 Retirement 

, 16 Sip feeds ! 19 MUR ethics 20 Injury and illness I 22 Dispensing errors 


Retirement changes and you 

The government has proposed abolishing the default retirement age of 65. Lawyer Gareth 
Edwards explains what the impact will be on pharmacists - and their pensions 

urrently, when employees 
reach 65, employers can 
^ „* compulsorily retire them 
without making any payment, 
providing the statutory retirement 
procedure has been followed. But 
this is all set to change, as the 
government has proposed the 
abolition of the default retirement 
age from October 2011 
Who will be affected? 
All employees, apart from those due 
to retire - at 65 or later - before 
October 2011 In fact, the change in 
the law will affect some employees 
before 2011 because the 
government is also abolishing the 
statutory retirement procedures. 
These require the employer to give 
the retiring employee at least six 
months notice of retirement, which 
means notice under the existing 
regime must be given by April 1, 
2011. To accommodate the change 
the government says it will 
introduce transitional arrangements 
by April 2011. 

Will my employer be able to force 
me to retire before I want to? 
It depends when you want to retire. 
Currently if you want to work 
beyond 65 you only have the right to 
ask your employer if you can do so. 
The employer does not have to 
agree to your request and does not 
have to give any reason for the 
decision, either. 

Under the proposed legislation, 
employees who want to work 
beyond 65 should be able to do so 
more easily. However, it will depend 
on the steps the employer takes. 
Some employers, notably B&Q, 
Nationwide, BT and M&S already 
have no compulsory retirement age. 
Many employers may follow their 
example. This probably means that 
employees will be left to come to 
their own decisions about when to 
retire, although it will be necessary 
for employers to manage 
employees' capabilities and 
performance. An open retirement 
age may prompt more dismissals on 
performance or capability grounds. 

Other employers may decide to 
set their own compulsory retirement 

Proposed new rules will enable employers to set compulsory retirement ages 

age, which the new legislation will 
allow them to do. Managing 
retirement will become difficult for 
employers as they will need to be 
able to justify objectively the 
retirement age they set. 

As yet there is little in the way of 
guidelines, but factors employers 
will need to consider may well 
include: health and safety 
considerations; the need to produce 
a happy workplace, and the need to 
give younger employees the 
opportunity for promotion. The onus 
will be on the employer to justify 
their decision. A retirement will be a 
dismissal and the employee can 
challenge the dismissal at an 
employment tribunal. 

The changes are likely to create 
uncertainty for employers and 
employees alike until test cases can 
clarify the reasons an employer can 
use to justify the setting of a 
retirement age. 

Will my employer be able to 
prevent me from retiring when I 
want to? 

No. In order to retire it will still be 

possible for you to resign, giving 
notice under the terms of your 
contract of employment, and it will 
be extremely rare for an employer to 
refuse to accept your resignation. 
How will the changes affect my 
pension entitlements? 
One advantage of the default 
retirement age is that the employee 
qualifies for their state pension on 
retirement. This will change. Already 
the government is discussing plans 
to extend the age at which people 
can claim their state pension 

Private pension providers may see 
a change in the legislation as an 
opportunity to delay the age a 
pension can be claimed, in order to 
allow them to build up funds and to 
take account of the likelihood that 
people will be living longer. 

However, if employers set a 
compulsory retirement age they 
ought to ensure that any pension 
scheme they provide will be flexible 
enough to permit this 
Gareth Edwards is a partner in the 
employment team at Veale 
Wasbrough Vizards 

CPD Reflect • Plan • Act • Evaluate 

Tips for your CPD entry on retirement law changes 


How will the abolition of the default retirement age affect 
me or my employees? 


Familiarise yourself with the new regulations. 


Make sure you or your employees understand how these 
regulations will be applied in your pharmacy. 


Do 1 understand how the abolition of the default 
retirement age will affect me or my employees? 

How employers 
should handle 
changes to 
retirement age 

The abolition of the default 
retirement age presents 
employers with two options. 
First, employers can decide not 
to have a compulsory retirement 
age, but they will have to have 
clear policies and procedures 
dealing with capability and 
performance in order to manage 
employees whose performance 
may decline as they get older. 

Second, employers can set 
their own compulsory retirement 
age, but will have to be able to 
justify it objectively. 

Either option presents 
employers with new problems 
and uncertainties. Capability and 
performance management may 
be difficult or unpleasant when 
dealing with an employee who 
has given years of loyal service. 

Setting a compulsory 
retirement age is also fraught 
with problems. The employer 
may retire the employee but it 
will be a dismissal and so the 
employee can make a claim to 
an employment tribunal. Claims 
will include unfair dismissal, 
redundancy and age 
discrimination. Employers will 
need to satisfy the tribunal that it 
is a retirement, that they have 
followed a fair procedure and be 
able to justify objectively the 
retirement age they have set. If 
the employer fails in these tasks 
they face paying tribunal awards 
for unfair dismissal, which is 
capped at £65,300, or 
compensation for discrimination, 
which is uncapped. 

Ahead of the proposed 
changes, employers with 
employees coming up to 65 
should ensure the correct notices 
- at least six months - are given 
under existing statutory 
retirement procedures. 

28.08.10 25 


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26 Chemist-Druggist 28.08.10 

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28.08.10 Chemist >ist 27 


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Got a story for Postscript? 

Phoenix ready to ride again 

Next week 56 cyclists will cycle 300 miles from 
London to Paris. But they're not just doing it for 
fun - it's a bid to raise £500,000 for Great 
Ormond Street Children's Hospital. 

The Phoenix London to Paris bike ride is now in 
its 10th and final year, having raised a whopping 
£377,000 for the hospital since its inception. 

Cyclists include Phoenix group company 
secretary Mike Blakeman and customer Marshall 
Glynn, two of only three to have ridden all 10. 

How much have you raised so far? I have raised 
£2,300, which has beaten my target of £2,000. 

Are you looking forward to the cycle? I am 

looking forward to the challenge and know it will 
take a great deal of physical ability but also a lot of 
psychological strength, too. 

What kind of training have you done? I have 
been out on my bike most mornings before work 
doing about 15 to 20 miles, and when able also at 
weekends doing longer rides of 30 to 40 miles. 

Will you doit again? I would probably he in a 
better position to answer that once I'm sat with a 
cold beer in Paris, but I would like to think I would. 

They will be cycling alongside Phoenix CEO Paul 
Smith, who set the bike ride up 10 years ago, and 
C+D's projects director Patrick Grice is also 
donning Lycra for the good cause. 

Mike Johnson, Rowlands' marketing manager, 
who completed the challenge last year, described 
the end of the ride as a great experience. 

He said: "The sense of achievement was 
incredible. There were celebratory hugs, kisses and 
firm handshakes under the Eiffel Tower but it was 
straight to the hotel to start the celebrations 
properly with a glass of well-earned champagne." 
You can sponsor the cyclists who are riding for 
Great Ormond Street Children's Hospital at 

A view from the saddle 

Numark managing director Tony Mottram is going to do the 
enix London to Paris bike ride for the first time this month 

Why are you raising money for Great Ormond 
Street Hospital? It's a charity that Phoenix has 
supported for the past 10 years. On a personal 
level my wife and I became parents in October last 
year and we are very fortunate to have a happy, 
healthy baby girl. I know there are some parents 
who are less fortunate as their children have no 
choice but to fight illness. Great Ormond Street 
Hospital is an organisation that helps children 
battle illness and provides support for parents at a 
time of huge challenge. 

Calling all pharmacists and technicians. We 
want you to be our reader of the week. Email 
us at 

@The Web Hunter 

I got slammed for my last column - and probably 
justifiably - for asking what the fuss was about 
Sainsbury's vending machines. 

One commenter asked me how I would feel if 
someone found a clever machine to do my job. 
Ironically, in the US they have come up with a 
computer programme that can write sports 
reports, so maybe my end is nearer than I think. 

This week Lloydspharmacy has been looking 
into all-in-one 'health villages', which have been 
praised by another commenter as good and clever 
thinking. And Boots' online private prescription 
service also won plaudits. 

Both of the above examples, to me at least, 
seem like innovative thinking in an increasingly 
competitive market. And neither of them could be 
replicated by independent pharmacies, or indeed 
by smaller multiples or chains. 

Now I don't want to keep poking a wasp nest by 
bringing these things up, but Superdrug's move to 
cut prescription charges and Sainsbury's vending 
machines are also innovative ways of gaining an 
advantage in the same competitive market. 

Don't get me wrong, I am not saying: "Well, 
that's market forces, you had better get used to 
them." But what I would like to know is why your 
average Joe Pharmacist doesn't complain when 
Boots or Lloyds does something clever, but 
complains bitterly when it is done by a 
supermarket chain or a health and beauty 
retailer? Surely they all hit small pharmacists and 
have implications for pharmacy services. 

The problem is that there are some pharmacists 
who consider themselves medical professionals 
first and retailers second: a group that isn't that 
good, necessarily, at retail. Then there are those 
who consider themselves medicinal retailers, who 
are good at marketing their services while 
maintaining a professional approach. 

And last there are health and beauty retailers, 
who also happen to provide pharmacy services. 
And this is the group that many of you seem to 
have a problem with. 

Am I getting close? Why is this? And which 
category do you fall into? Let me know - email, or leave a comment at 
Niall Hunt is C+D's digital content editor 

Last week's top stories 
on C+D's website 

1. RPSGB boards slam proposed GPhC fees 

2. Boots launches online prescription service 

3. Lloydspharmacy investigates all-in-one 'health 

30 Chemist Druggist 28.08.10 

The C+D Conference 

* NEC Birmingham 10-11 October 2010 

Andy Murdock 

Pharmacy Director 
A multiple's view of 
the new look NHS 



Mark James 

Managing Director 

Wholesaling, big 
pharma and you 

Chris Brooker 
Business Director 
Co-operative Pharmacy 
Learning from the Co-op 
blueprint for success 

Got a question for any of the speakers? Email it to 


We're sending you 
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Now get the training 
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In September, the high-impact consumer campaign for Flomax 
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They'll be expecting you to be specially trained to help them get 
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Men tend to behave in a reactionary way to healthcare services, 1 
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/|T\ Boehringer Flomax Relief MR - Product Information. Presentation: Flomax Relief 
Ingelheim containing 0.4mg of tamsulosin hydrochloride in a modified release 

capsule Indication: Treatment ot functional symptoms of benign prostatic hyperplasia 
(BPH). Dosage: For men aged 45-75 years. For oral use. One capsule daily Contraindications: 
Hypersensitivity to any ingredients of the product; a history of orthostatic hypotension; 
severe hepatic insufficiency. Warnings and Precautions: Men taking an antihypertensive 
alpha^adrenoceptor blocker should consult a doctor before taking Flomax Relief. In individual 
cases a fall in blood pressure can occur. Do not give to a man who experiences postural 
hypotension. Consult a doctor before taking Flomax Relief if a man has heart, renal, or liver 
disease, uncontrolled diabetes, urinary incontinence, ot has had prostate surgery. Do not 
supply Flomax Relief to a man whose symptoms are of less than 3 months' duration. Do not 
supply to a man who reports dysuria, haematuria. or cloudy urine, in the previous 3 months, 
or who has a fever that might be related to urinary tract infection. Do not initiate treatment in 
a man planning cataract surgery, or who has recently experienced blurred or cloudy vision 
not examined by a doctor or optician. If urinary symptoms have not improved within 14 days 
of starting treatment the patient should be referred to a doctor. Medical review is required for 

Date ot preparation August 2010/FMX0258 

diagnosis of BPH: Patients must see their doctor within 6 weeks of starting treatment for 
assessment of their symptoms and confirmation to continue taking Flomax Relief long-term 
from their pharmacist. Every 12 months, patients should be advised to consult a doctor. 
Adverse Effects: Common: dizziness. Uncommon: headache, palpitations, postural hypotension, 
rhinitis, constipation, diarrhoea, nausea, vomiting, rash, pruritus, urticaria, abnormal 
ejaculation, asthenia. Rare; syncope, angioedema. Very rare: priapism. Drowsiness, blurred 
vision, dry mouth or oedema can occur. IFIS has occurred in some patients during cataract 
surgery. RRP (ex VAT): 14 capsules £7.65, 28 capsules C14.46 Legal Category: P Product 
Licence Number: PL 00015/0280 Date of revision: December 2009. Further information 
available from: Boehnngei Ingelheim Limited. Consumer Healthcare, Ellesfield Avenue, Bracknell, 
Berkshire RG12 8YS. Reference: 1. Granville G. Racks of make-up and no spanners. Men's 
Health Forum Report. September 2009. 

Adverse events should be reported. Reporting forms and information can be found 
at Adverse events should also be reported to Boehringer 
Ingelheim Drug Safety on 0800 328 1627 (freephone).